Topics in Geriatrics: Treatment Strategies for Falling
Falls are currently recognized as the leading cause of injury and injury related death for older adults living in the United States [1]. Therefore, it’s critical to identify the risk factors and impairments that can negatively impact balance and provide effective interventions to decrease fall risk.
Objectives:
The objectives of this page are to:
1. Learn about risk factors that may contribute to falls.
2. Learn about the best fall screening and assessment tools to determine who is at high risk for falls.
3. Learn about treatment strategies and interventions to decrease fall risk within the geriatric population.
4. Learn about who each treatment strategy and intervention should be used with.
5. Learn about the evidence regarding each fall screen, assessment, treatment strategy and intervention.
Information About the Test, Condition or Topic:
Fall Risk Factors: Balance is comprised of three different sensory systems in our bodies working in unison to keep us upright. These components are our vision, somatosensation, and vestibular systems. There are several factors that can contribute to poor balance and therefore lead to an increased risk for falling. Some of which are modifiable while others may remain more constant throughout our lifetime. To ensure patient safety and create successful treatment outcomes it is imperative for physical therapists and all other medical personal to be able to recognize these fall risk factors and then put an effective plan of care together to help correct the modifiable risk factors and develop compensatory strategies to work around the non-modifiable components that might negatively affect balance.
A non-exclusive list of some modifiable risk factors that patients with poor balance might present with are as follows: acute illness (such as ear infections, chest infections, urinary tract infections, etc.), poor nutrition and dehydration, visual problems, gait and mobility impairments, continenceproblems (urinary urgency & nocturia), postural hypotension (a fall in systolic blood pressure of 20mmHg or more when changing positions), polypharmacy (4 or more medications indicates increased fall risk), and home/environmental hazards. Additional fall risk factors include decreased strength, poor/incorrect posture, fear of falling and vestibular hypofunction. Each of the risk factors listed above can be corrected with proper medical treatment. Prevention of some of these risk factors is also possible by attending routine physician check-ups, participating in balance screens, and staying active and eating healthy [2, 3, 4].
Non-modifiable risk factors that contribute to decreased balance may include but are not limited to the following undiagnosed diseases such as dementia, stroke, Parkinson’s disease, diabetes mellitus, etc. With dementia, the decline in cognition can lead to decreased safety awareness and/or recognition of potential hazards. Patients who suffer from stroke may experience lingering impairments that will affect their gait and balance. These affects are dependent on the specific area(s) of the brain that were damaged. Some of the most common impairments seen after experiencing a stroke include hemiparesis, spasticity, visual loss, unilateral neglect, etc. Patients who are diagnosed with Parkinson’s disease present with a forward flexed posture, which alters their center of gravity, festinating gait and freezing while ambulating along with difficulty producing the appropriate amount of muscle force generated to safely and successfully carry out activities of daily living. Patients who are diabetic typically do not live an active lifestyle as compared to their peers who are not diabetic and previous studies have shown that sedentary lifestyles and inactivity contribute to weaker muscles, poorer balance and therefore an increased risk for falls. Additionally, most people who are diagnosed with diabetes experience neuropathy in their feet, which disrupts their somatosensory input, again leading to increased fall risk [2,3].
Fall Screening & Assessment Tools: As of today, there are numerous fall screens and balance assessment tools out there to choose from. This potentially makes selecting the most appropriate method for your patient a challenge if you’re not familiar with the different alternatives. In order to maximize efficiency in the clinic the therapist must select a balance-screening tool that is timely yet also provides all the relevant information needed by its completion. The following are some of the more well-established and reliable balance screening tools used.
Implementing the Activities of Balance Confidence (ABC) Scale can best assess fear of falling. This brief questionnaire is a 16-item self-reported outcome measure that allows patients to rate their confidence when completing each of the activities listed and can be completed in a matter of 5-10 minutes. Patients can rate themselves on a scale from 0% (indicating no confidence) to 100% (complete confidence) for each activity. Once completed, the therapist will then add up all the totals from each section and then divide that number by 16 to get their overall score or %. Scores < 67% indicate that the patient is at a higher risk for falls [5].
The 4-Stage Balance Test is an effective tool used to assess static balance. The patient starts off by attempting to stand with their feet together for 10 seconds, then they progress to standing semi-tandem for 10 seconds, followed by standing in tandem stance for 10 seconds, and the last stage is standing on one leg for 10 seconds. An older adult who cannot hold tandem stance for at least 10 seconds is deemed to be at higher risk for falls [5].
The Berg Balance Scale is an outcome measure used to assess both static and dynamic balance. This scale consists of 14-items that are scored 0-4 with 4 being the highest score attainable for each activity. 56 is the max score attainable and scores <45 indicate increased risk for falls. Items needed to complete this assessment include a stopwatch, a chair with arm rests, a measuring tape, an object to pick up off the floor, and a step stool. This assessment usually takes 15-20 minutes to administer [5].
The Functional Gait Assessment (FGA) is a modified version of the Dynamic Gait Index and is a 10-item tool used to evaluated gait, balance, and fall risk. Scoring is based on an ordinal scale of 0-3 with 0 indicating that the patient was unable to complete the task and 3 indicated normal ambulation with no deviations. The maximum score one can achieve is a 30 with the fall risk cutoff being set at < or = 22/30. A stopwatch, an object of 9 inches in height, a set of stairs, and 20 foot marked off area for walking are all needed to implement this test. Testing time should take no longer than 10 minutes per patient [5].
The Timed Up & Go (TUG) Test is an additional balance, mobility and fall risk assessment that only takes a few minutes to administer. This test starts off by having a patient sit down in a chair without armrests, they then rise to a standing position and walk as fast, but as safely as they can to an object that’s place 3 meters away from the chair, they walk around this object and then come back to the chair and sit down completely. The therapist times the patient from beginning to end and scores of > or = 12 seconds indicate increased risk for falls. The nice aspect of this test is that you can add in cognitive and manual task components to increase its difficulty and simulate multitasking [5].
Treatment Strategies & Interventions to Decrease Fall Risk: There are a variety of different treatment strategies and physical therapy interventions that have been proven to be reliable and effective in treating balance deficiencies. The specific strategy selected is dependent upon the impairment(s) that your patient presents with. Both resistive strength training and cardiovascular focused exercise programs have resulted in improvements in balance and therefore decreased overall fall risk. With this being said, a collaborative effort combining these two treatment strategies produced the greatest outcomes [6]. Along with this, specific balance strategies have also been proven to show improvements in decreasing fall risk. An example of this is using a wobble board and working on weight shifting in both the anterior-posterior direction and laterally. Additional treatment sessions focused on maintaining horizontal balance on the wobble board [7]. Proprioceptive training has also been deemed to be effective in treating balance impairments when implemented at least twice a week and performing exercises on a Swiss ball and/or BOSU [8]. A newer intervention to treat fall risk that requires patients to be higher functioning and have less severe balance impairments is Tai Chi. This dynamic form of exercise concentrates on core strength and flexibility, which by making improvements in these areas will directly lead to improved balance and decreased fall risk [9]. Group exercise classes have also shown significant results and can improve social well-being in addition to seeing physical improvements and decreasing fall risk [10]. An example of this is A Matter of Balance. Finally, and this is the easiest and cheapest strategy to implement, is getting a home assessment completed and making home/environmental modifications to help decrease your patient’s risk for falls. Some examples of these modifications include removing throw rugs, decreasing clutter, increasing lighting and avoiding seats that are very low to the ground [11]. This list of treatment strategies and interventions isn’t exclusive but provides some of the newer, more reliable methods to improve balance and decrease fall risk. A valid and reliable plan of care to treat balance impairments should consist of some combination of the treatment strategies listed above.
Which Treatment Strategy & Intervention is Most Appropriate for my Patient: There is no straightforward answer to this question. Instead, the physical therapist must account for all of the risk factors that their patient presents with along with their age, race and gender and tailor a plan of care to their specific needs and goals. For instance, if the patient is lower level then maybe selecting more basic static balance tests and implementing easier resistance and cardiovascular exercises is the strategy to go with. On the other hand, if you have a more ambitious and higher level patient then challenging dynamic exercises such as Tai Chi might be more appropriate. Regardless of the level of patient you are treating there are important aspects of treatment that should remain consistent. These aspects are that you correctly identify their fall risk factors, actively listen to their concerns and what their goals are for participating in therapy/rehab, and develop and implement a plan of care that is salient to the patient. By following these guidelines you are helping to set your patient up for success from the very start.
Evidence for Use of Fall Screens, Assessments, Treatment Strategies, and Interventions: A systematic review conducted back in 2012 determined that there is poor external validity for the fall screens, assessments and interventions listed above [12]. With this being said, the outcome measures listed are still appropriate for most, but not all patients who have impaired balance and are at high risk for falls. Along with this, the ABC Scale, Berg Balance Scale, FGA, and TUG all have excellent test-retest reliability, interrater and intrarater reliability, and criterion validity [5]. As stated earlier, combined exercise prescriptions incorporating both resistive strengthening and cardiovascular endurance produce better results when it comes to treating balance impairments rather than focusing on simply one or the other. Additionally, specific balance training with use of a wobble board, proprioceptive training, Tai Chi, and group exercise classes have all shown to improve balance within the geriatric population [13].
Suggestions:
Home Modifications: This is the cheapest and easiest way to ensure safety and decrease fall risk within the home environment.
Participate in Group Exercise Classes: Participation in in group exercise classes has been shown to enhance patient’s social well being, participants are able to help hold each other accountable to increase attendance and adherence to the program, it eliminates the fear of being the only person in your specific situation and therefore possibly avoiding going out in public, and finally, a variety of classes are normally offered for free at numerous facilities such as local YMCAs, which offers the Silver Sneakers Program for free once you purchase a gym membership.
Schedule Regular Physician Check-ups: Regular physician check ups and visits can help with prevention of diseases and illnesses and early detection if a disease or illness is present. If any new concerns arise, these visits will allow the patient to express them and get referrals as deemed necessary.
Attend Physical Therapy: If your patient is seriously concerned with falling or has experienced falls in the past then they should be encouraged to attend physical therapy to improve their balance. Most people aren’t aware of this aspect of physical therapy and don’t realize that their balance can be improved. Perhaps the best way to quantitatively evaluate balance is via NeuroCom Smart Balance Master, which is a state of the art machine used in neurological/vestibular clinics.
Stay Active: As we age our bodies require more effort to maintain our current physical fitness level so it’s imperative to complete some form of moderate exercise each day for a minimum of 150 minutes total for the week [14].
2. SunYoung, H., & Heeok, P. (2017). A Meta-analysis of the Risk Factors related to Falls among Elderly Patients with Dementia. Korean Journal Of Adult Nursing, 29(1), 51-62.
3. Nazarko, L. (2015). Modifiable risk factors for falls and minimizing the risk of harm. Nurse Prescribing, 13(4), 192-198.
4. Cox, T. B., & Williams, K. (2016). Fall Recovery Intervention and its Effect on Fear of Falling in Older Adults. Activities, Adaptation & Aging, 40(2), 93-106.
5. www.rehabmeasures.org
6. Sousa, N., Mendes, R., Silva, A., & Oliveira, J. (2017). Combined exercise is more effective than aerobic exercise in the improvement of fall risk factors: a randomized controlled trial in community-dwelling older men. Clinical Rehabilitation, 31(4), 478-486.
7. Smee, D. J., Berry, H. L., Waddington, G. S., & Anson, J. M. (2014). A Balance-Specific Exercise Intervention Improves Falls Risk but not Total Physical Functionality in Community-Dwelling Older Adults. Physical & Occupational Therapy In Geriatrics, 32(4), 310-320.
8. Emilio, E. M., Hita-Contreras, F., Jiménez-Lara, P. M., Latorre-Román, P., & Martínez-Amat, A. (2014). The Association of Flexibility, Balance, and Lumbar Strength with Balance Ability: Risk of Falls in Older Adults. Journal Of Sports Science & Medicine, 13(2), 349-357.
9. Sungkarat, S., Boripuntakul, S., Chattipakorn, N., Watcharasaksilp, K., & Lord, S. R. (2017). Effects of Tai Chi on Cognition and Fall Risk in Older Adults with Mild Cognitive Impairment: A Randomized Controlled Trial. Journal Of The American Geriatrics Society, 65(4), 721-727.
10. Lee Smith, M., SangNam, A., Mier, N., Luohua, J., & Ory, M. G. (2012). An Evidence-Based Program to Reduce Fall-Related Risk Among Older Adults: A Comparison of Program Efficacy by Ethnicity. Californian Journal Of Health Promotion, 10(1), 28-43.
11. Stark, S., Keglovits, M., Arbesman, M., & Lieberman, D. (2017). Effect of Home Modification Interventions on the Participation of Community-Dwelling Adults With Health Conditions: A Systematic Review. American Journal Of Occupational Therapy, 71(2), 1-11.
12. McMahon, S., & Fleury, J. (2012). External validity of physical activity interventions for community-dwelling older adults with fall risk: a quantitative systematic literature review. Journal Of Advanced Nursing, 68(10), 2140-2154.
13. Robinson, B., Gordon, J., Wallentine, S., & Visio, M. (2002). Effectiveness of physical therapy intervention in decreasing the risk for falls in a community-dwelling aging population. Orthopaedic Nursing, 21(1), 55-69.
Falls are currently recognized as the leading cause of injury and injury related death for older adults living in the United States [1]. Therefore, it’s critical to identify the risk factors and impairments that can negatively impact balance and provide effective interventions to decrease fall risk.
Objectives:
The objectives of this page are to:
Information About the Test, Condition or Topic:
Fall Risk Factors: Balance is comprised of three different sensory systems in our bodies working in unison to keep us upright. These components are our vision, somatosensation, and vestibular systems. There are several factors that can contribute to poor balance and therefore lead to an increased risk for falling. Some of which are modifiable while others may remain more constant throughout our lifetime. To ensure patient safety and create successful treatment outcomes it is imperative for physical therapists and all other medical personal to be able to recognize these fall risk factors and then put an effective plan of care together to help correct the modifiable risk factors and develop compensatory strategies to work around the non-modifiable components that might negatively affect balance.
A non-exclusive list of some modifiable risk factors that patients with poor balance might present with are as follows: acute illness (such as ear infections, chest infections, urinary tract infections, etc.), poor nutrition and dehydration, visual problems, gait and mobility impairments, continence problems (urinary urgency & nocturia), postural hypotension (a fall in systolic blood pressure of 20mmHg or more when changing positions), polypharmacy (4 or more medications indicates increased fall risk), and home/environmental hazards. Additional fall risk factors include decreased strength, poor/incorrect posture, fear of falling and vestibular hypofunction. Each of the risk factors listed above can be corrected with proper medical treatment. Prevention of some of these risk factors is also possible by attending routine physician check-ups, participating in balance screens, and staying active and eating healthy [2, 3, 4].
Non-modifiable risk factors that contribute to decreased balance may include but are not limited to the following undiagnosed diseases such as dementia, stroke, Parkinson’s disease, diabetes mellitus, etc. With dementia, the decline in cognition can lead to decreased safety awareness and/or recognition of potential hazards. Patients who suffer from stroke may experience lingering impairments that will affect their gait and balance. These affects are dependent on the specific area(s) of the brain that were damaged. Some of the most common impairments seen after experiencing a stroke include hemiparesis, spasticity, visual loss, unilateral neglect, etc. Patients who are diagnosed with Parkinson’s disease present with a forward flexed posture, which alters their center of gravity, festinating gait and freezing while ambulating along with difficulty producing the appropriate amount of muscle force generated to safely and successfully carry out activities of daily living. Patients who are diabetic typically do not live an active lifestyle as compared to their peers who are not diabetic and previous studies have shown that sedentary lifestyles and inactivity contribute to weaker muscles, poorer balance and therefore an increased risk for falls. Additionally, most people who are diagnosed with diabetes experience neuropathy in their feet, which disrupts their somatosensory input, again leading to increased fall risk [2,3].
Fall Screening & Assessment Tools: As of today, there are numerous fall screens and balance assessment tools out there to choose from. This potentially makes selecting the most appropriate method for your patient a challenge if you’re not familiar with the different alternatives. In order to maximize efficiency in the clinic the therapist must select a balance-screening tool that is timely yet also provides all the relevant information needed by its completion. The following are some of the more well-established and reliable balance screening tools used.
Implementing the Activities of Balance Confidence (ABC) Scale can best assess fear of falling. This brief questionnaire is a 16-item self-reported outcome measure that allows patients to rate their confidence when completing each of the activities listed and can be completed in a matter of 5-10 minutes. Patients can rate themselves on a scale from 0% (indicating no confidence) to 100% (complete confidence) for each activity. Once completed, the therapist will then add up all the totals from each section and then divide that number by 16 to get their overall score or %. Scores < 67% indicate that the patient is at a higher risk for falls [5].
The 4-Stage Balance Test is an effective tool used to assess static balance. The patient starts off by attempting to stand with their feet together for 10 seconds, then they progress to standing semi-tandem for 10 seconds, followed by standing in tandem stance for 10 seconds, and the last stage is standing on one leg for 10 seconds. An older adult who cannot hold tandem stance for at least 10 seconds is deemed to be at higher risk for falls [5].
The Berg Balance Scale is an outcome measure used to assess both static and dynamic balance. This scale consists of 14-items that are scored 0-4 with 4 being the highest score attainable for each activity. 56 is the max score attainable and scores <45 indicate increased risk for falls. Items needed to complete this assessment include a stopwatch, a chair with arm rests, a measuring tape, an object to pick up off the floor, and a step stool. This assessment usually takes 15-20 minutes to administer [5].
The Functional Gait Assessment (FGA) is a modified version of the Dynamic Gait Index and is a 10-item tool used to evaluated gait, balance, and fall risk. Scoring is based on an ordinal scale of 0-3 with 0 indicating that the patient was unable to complete the task and 3 indicated normal ambulation with no deviations. The maximum score one can achieve is a 30 with the fall risk cutoff being set at < or = 22/30. A stopwatch, an object of 9 inches in height, a set of stairs, and 20 foot marked off area for walking are all needed to implement this test. Testing time should take no longer than 10 minutes per patient [5].
The Timed Up & Go (TUG) Test is an additional balance, mobility and fall risk assessment that only takes a few minutes to administer. This test starts off by having a patient sit down in a chair without armrests, they then rise to a standing position and walk as fast, but as safely as they can to an object that’s place 3 meters away from the chair, they walk around this object and then come back to the chair and sit down completely. The therapist times the patient from beginning to end and scores of > or = 12 seconds indicate increased risk for falls. The nice aspect of this test is that you can add in cognitive and manual task components to increase its difficulty and simulate multitasking [5].
Treatment Strategies & Interventions to Decrease Fall Risk: There are a variety of different treatment strategies and physical therapy interventions that have been proven to be reliable and effective in treating balance deficiencies. The specific strategy selected is dependent upon the impairment(s) that your patient presents with. Both resistive strength training and cardiovascular focused exercise programs have resulted in improvements in balance and therefore decreased overall fall risk. With this being said, a collaborative effort combining these two treatment strategies produced the greatest outcomes [6]. Along with this, specific balance strategies have also been proven to show improvements in decreasing fall risk. An example of this is using a wobble board and working on weight shifting in both the anterior-posterior direction and laterally. Additional treatment sessions focused on maintaining horizontal balance on the wobble board [7]. Proprioceptive training has also been deemed to be effective in treating balance impairments when implemented at least twice a week and performing exercises on a Swiss ball and/or BOSU [8]. A newer intervention to treat fall risk that requires patients to be higher functioning and have less severe balance impairments is Tai Chi. This dynamic form of exercise concentrates on core strength and flexibility, which by making improvements in these areas will directly lead to improved balance and decreased fall risk [9]. Group exercise classes have also shown significant results and can improve social well-being in addition to seeing physical improvements and decreasing fall risk [10]. An example of this is A Matter of Balance. Finally, and this is the easiest and cheapest strategy to implement, is getting a home assessment completed and making home/environmental modifications to help decrease your patient’s risk for falls. Some examples of these modifications include removing throw rugs, decreasing clutter, increasing lighting and avoiding seats that are very low to the ground [11]. This list of treatment strategies and interventions isn’t exclusive but provides some of the newer, more reliable methods to improve balance and decrease fall risk. A valid and reliable plan of care to treat balance impairments should consist of some combination of the treatment strategies listed above.
Which Treatment Strategy & Intervention is Most Appropriate for my Patient: There is no straightforward answer to this question. Instead, the physical therapist must account for all of the risk factors that their patient presents with along with their age, race and gender and tailor a plan of care to their specific needs and goals. For instance, if the patient is lower level then maybe selecting more basic static balance tests and implementing easier resistance and cardiovascular exercises is the strategy to go with. On the other hand, if you have a more ambitious and higher level patient then challenging dynamic exercises such as Tai Chi might be more appropriate. Regardless of the level of patient you are treating there are important aspects of treatment that should remain consistent. These aspects are that you correctly identify their fall risk factors, actively listen to their concerns and what their goals are for participating in therapy/rehab, and develop and implement a plan of care that is salient to the patient. By following these guidelines you are helping to set your patient up for success from the very start.
Evidence for Use of Fall Screens, Assessments, Treatment Strategies, and Interventions: A systematic review conducted back in 2012 determined that there is poor external validity for the fall screens, assessments and interventions listed above [12]. With this being said, the outcome measures listed are still appropriate for most, but not all patients who have impaired balance and are at high risk for falls. Along with this, the ABC Scale, Berg Balance Scale, FGA, and TUG all have excellent test-retest reliability, interrater and intrarater reliability, and criterion validity [5]. As stated earlier, combined exercise prescriptions incorporating both resistive strengthening and cardiovascular endurance produce better results when it comes to treating balance impairments rather than focusing on simply one or the other. Additionally, specific balance training with use of a wobble board, proprioceptive training, Tai Chi, and group exercise classes have all shown to improve balance within the geriatric population [13].
Suggestions:
Home Modifications: This is the cheapest and easiest way to ensure safety and decrease fall risk within the home environment.
Participate in Group Exercise Classes: Participation in in group exercise classes has been shown to enhance patient’s social well being, participants are able to help hold each other accountable to increase attendance and adherence to the program, it eliminates the fear of being the only person in your specific situation and therefore possibly avoiding going out in public, and finally, a variety of classes are normally offered for free at numerous facilities such as local YMCAs, which offers the Silver Sneakers Program for free once you purchase a gym membership.
Schedule Regular Physician Check-ups: Regular physician check ups and visits can help with prevention of diseases and illnesses and early detection if a disease or illness is present. If any new concerns arise, these visits will allow the patient to express them and get referrals as deemed necessary.
Attend Physical Therapy: If your patient is seriously concerned with falling or has experienced falls in the past then they should be encouraged to attend physical therapy to improve their balance. Most people aren’t aware of this aspect of physical therapy and don’t realize that their balance can be improved. Perhaps the best way to quantitatively evaluate balance is via NeuroCom Smart Balance Master, which is a state of the art machine used in neurological/vestibular clinics.
Stay Active: As we age our bodies require more effort to maintain our current physical fitness level so it’s imperative to complete some form of moderate exercise each day for a minimum of 150 minutes total for the week [14].
Additional Resources:
YMCA Silver Sneakers: https://www.silversneakers.com/learn/
A Matter of Balance: https://www.ncoa.org/resources/program-summary-a-matter-of-balance/
Fall Risk Screening & Assessment Forms:
- ABC Scale: https://drayerpt.com/content/uploads/2015/10/Balance-Gait-Falls-ABC-Scale.pdf
- 4 Stage Balance Test: https://www.cdc.gov/steadi/pdf/4-stage_balance_test-a.pdf
- Berg Balance Scale: http://www.aahf.info/pdf/Berg_Balance_Scale.pdf
- Functional Gait Assessment: http://geriatrictoolkit.missouri.edu/FGA/Wrisley-2007-FGA_PTJ_84-10-Appendix.pdf
- Timed Up & Go: https://www.cdc.gov/steadi/pdf/tug_test-a.pdf
Fall Risk Check List: https://www.cdc.gov/steadi/pdf/stay_independent_brochure-a.pdf
Home Modification Check List: https://www.ncoa.org/blog/falls-prevention-home-18-step-safety-checklist/
References:
1. Falls Prevention Facts. (2016). https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/
2. SunYoung, H., & Heeok, P. (2017). A Meta-analysis of the Risk Factors related to Falls among Elderly Patients with Dementia. Korean Journal Of Adult Nursing, 29(1), 51-62.
3. Nazarko, L. (2015). Modifiable risk factors for falls and minimizing the risk of harm. Nurse Prescribing, 13(4), 192-198.
4. Cox, T. B., & Williams, K. (2016). Fall Recovery Intervention and its Effect on Fear of Falling in Older Adults. Activities, Adaptation & Aging, 40(2), 93-106.
5. www.rehabmeasures.org
6. Sousa, N., Mendes, R., Silva, A., & Oliveira, J. (2017). Combined exercise is more effective than aerobic exercise in the improvement of fall risk factors: a randomized controlled trial in community-dwelling older men. Clinical Rehabilitation, 31(4), 478-486.
7. Smee, D. J., Berry, H. L., Waddington, G. S., & Anson, J. M. (2014). A Balance-Specific Exercise Intervention Improves Falls Risk but not Total Physical Functionality in Community-Dwelling Older Adults. Physical & Occupational Therapy In Geriatrics, 32(4), 310-320.
8. Emilio, E. M., Hita-Contreras, F., Jiménez-Lara, P. M., Latorre-Román, P., & Martínez-Amat, A. (2014). The Association of Flexibility, Balance, and Lumbar Strength with Balance Ability: Risk of Falls in Older Adults. Journal Of Sports Science & Medicine, 13(2), 349-357.
9. Sungkarat, S., Boripuntakul, S., Chattipakorn, N., Watcharasaksilp, K., & Lord, S. R. (2017). Effects of Tai Chi on Cognition and Fall Risk in Older Adults with Mild Cognitive Impairment: A Randomized Controlled Trial. Journal Of The American Geriatrics Society, 65(4), 721-727.
10. Lee Smith, M., SangNam, A., Mier, N., Luohua, J., & Ory, M. G. (2012). An Evidence-Based Program to Reduce Fall-Related Risk Among Older Adults: A Comparison of Program Efficacy by Ethnicity. Californian Journal Of Health Promotion, 10(1), 28-43.
11. Stark, S., Keglovits, M., Arbesman, M., & Lieberman, D. (2017). Effect of Home Modification Interventions on the Participation of Community-Dwelling Adults With Health Conditions: A Systematic Review. American Journal Of Occupational Therapy, 71(2), 1-11.
12. McMahon, S., & Fleury, J. (2012). External validity of physical activity interventions for community-dwelling older adults with fall risk: a quantitative systematic literature review. Journal Of Advanced Nursing, 68(10), 2140-2154.
13. Robinson, B., Gordon, J., Wallentine, S., & Visio, M. (2002). Effectiveness of physical therapy intervention in decreasing the risk for falls in a community-dwelling aging population. Orthopaedic Nursing, 21(1), 55-69.
14. https://www.acsm.org/docs/brochures/selecting-and-effectively-using-balance-training-for-older-adults.pdf